Health insurance in the United States is driven by competitive risk rating and is promoted as the best way to give policyholders optimal value for their money and to be fair to those with lower risks. In practice, however, competitive risk rating costs more than noncompetitive, universal systems of health insurance, and it erodes the basic function of insurance to spread infrequent large losses over a wide base. This article describes not only how risk rating covers least those with the greatest medical bills, but also how it has spawned a labyrinth of complex manipulations by insurance companies to charge more or pay less than actuarially fair risk rating would justify. The final section shows that even if risk rating were done fairly, it contradicts moral fairness. Many of the leading proposals for national health insurance do not address these practical and ethical issues. The medical profession and policymakers need to discuss them and take a stand on them.